Critical Cases - Torsades de pointes!


  • 37 yo female with no medical history complains of one week of nonbloody intermittent vomiting
  • She notes intermittent "electric shock" sensations down her arms into her hands
  • She complains of tremors in her hands
  • She notes gradual onset of yellowing of her sclera 
  • Denies abdominal pain, fevers, diarrhea, urinary symptoms


Vitals: T 99.1 BP 144/120 HR 91 RR 20 Pox 100% on RA

  • Appears agitated and tremulous
  • HEENT: +scleral icterus
  • Cardiac: no murmurs
  • Pulm: Lungs clear
  • Abd: Soft, nontender, +hepatomegaly
  • Extrem: no edema
  • Neuro: +resting tremor in hands



  • Denies medical history
  • She does report taking an unknown medication for unclear psychiatric diagnosis in the past but not for several months


  • Denies recreational drug use
  • +heavy ETOH use daily last use within 24 hrs


Initial Differential Diagnosis

  • ETOH withdrawal: +reported ETOH use with tremors, vomiting, elevated BP
  • Acute hepatitis: new jaundice suggestive of viral or ETOH induced hepatitis or possible overdose of hepatotoxic medication 


Workup and Management

  • IV access, cardiac monitor
  • NS bolus 1 L
  • FSBS: 101
  • Chem basic, CBC. liver profile, acute hepatitis panel


Lab Results:



Lab intepretation:

  • hypokalemia
  • pancytopenia with macrocytic anemia
  • elevated transaminases and bilirubin
  • Overall picture suggestive of chronic ETOH abuse and alcohol induced pancreatitis


Case progression:

  • Pt monitor shows this rhythm:



  • Pt is found to be pulseless
  • Rhythm is identified as polymorphic ventricular tachycardia: torsades de pointes
  • Pt defibrillated at 200 J with return of spontaneous circulation, she regains consciousness and is at baseline mental status
  • A subsequent ECG shows:

  • QTc = 562 ms


Diagnosis and Management

  • Prolonged QT from hypokalemia/hypocalcemia/hypomagnesemia from severe vomiting/malnutrition
  • Acute alcoholic hepatitis
  • Acute ETOH withdrawal
  • Patient immediately treated with 4g IV magnesium, 2g calcium gluconate and 40 meq IV potassium chloride
  • Admitted to intensive care unit for continued electrolyte replacement and monitoring
  • 2 subsequent episodes of pulseless polymorphic VT treated with defibrillation
  • She is started on a lidocaine infusion to shorten Qtc and considered for a transvenous pacemaker to attempt overdrive pacing
  • Patient subsequently became agitated with visual hallucinatinons and had a brief seizure thought likely due to delerium tremens: treated with phenobarbital
  • QT gradually decreases to 500 ms as electrolytes replaced


Learning Points

  • Consider prolonged QTc in any patient who presents with vomiting and obtain an ECG early
  • This is especially common in patients with alchohol abuse who are often malnourished 
  • Treat markedly prolonged Qtc with aggressive intravenous replacement of potassium, magnesium, and calcium
  • Consider isoproterenol to increase the HR which will shorten the QTc
  • Consider overdrive pacing for unstable patients: placement of a transvenous pacemaker to artificially increase HR to shorten the QTc
  • Treat unstable torsades as for unstable VT, with cardioversion for patients with a pulse and defibrillation in the absence of a pulse